Understand patients' lives, follow up after discharge

Slow down the hospital revolving door

For some patients, particularly senior citizens, the hospital can be like a revolving door. They're in and out of the hospital frequently, despite the best efforts of clinicians to keep them healthy in the community.

It may be that they don't understand their treatment plan, but in many cases, it's because the case managers who are coordinating their care don't understand their life situation and the obstacles they face in trying to stay healthy at home.

"The main factor that causes patients to come back to the hospital time and time again is lack of understanding on the part of the clinical staff about how patients take care of themselves once they leave the hospital. We have to take the time to find out what is going on in patients' lives and encourage them to be active participants in their own healthcare rather than passive ones," says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, consulting firm specializing in hospital case management.

Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY, case management consulting firm, adds that it's essential for case managers to conduct an in-depth assessment of patients, especially seniors. "While some seniors truly do have complex medical conditions that might result in frequent hospitalizations and readmissions, some of the reasons for these occurrences are actually related to non-medical issues. Case managers often spend time on the obvious medical/clinical/nursing issues, but unfortunately don't always spend sufficient time assessing the psychosocial, financial, and other issues that can have a great impact on a senior's ability to remain at home," Mullahy says.

Even if patients don't qualify for or need skilled nursing services, that doesn't mean they don't need some kind of care and support services at home. Many seniors are socially isolated and may not have friends and family to help with care, assist with meal preparation or pick up medication at the pharmacy.

Kizziar points out that a variety of factors can affect a patient's recovery at home.

Cultural practices, particularly involving diet, often can interfere with the recommendations for keeping a chronic condition under control, Kizziar says. For instance, heart failure patients should restrict their intake of sodium, but this may be difficult for someone whose cultural practices include eating starchy and high-sodium foods once a day. "They get home and they're going to eat what the rest of the family is eating," she says.

Polypharmacy issues are common, and many people with chronic conditions are on multiple medications. For instance, many times patients are discharged with different medications from the ones they were taking before hospitalization. "They don't know if they should take the new medications, the old ones, or all of them," she says.

Mullahy adds that seniors may have stopped driving and are hesitant about asking a neighbor to drive them to and from doctor visits or don't have access to public transportation. Vision and cognitive problems also can affect their ability to manage their care at home.

Case managers should explore support services, some of which may be funded by Medicare, supplemental insurance, long-term care insurance or a community program, Mullahy suggests. "As case managers we need to be vigilant in keeping ourselves updated on what is available and successful in the communities where our patients are located," she says.

Kizziar emphasizes that patients who are frequently hospitalized need more than just a follow-up phone call to ensure that they are recovering at home and adhering to their discharge plan. Some hospitals are creating specialty clinics for patients with heart failure, pulmonary conditions, diabetes, and other chronic illnesses. These clinics see patients within three or four days of discharge to follow up on their condition and review their medication, Kizziar says. "One of the drawbacks is that this requires patients to make the effort to come to the clinic and to find their own transportation," she says.

"We're encouraging hospitals to become more involved in seeing people in the home environment. They can see what is in the refrigerators, look for any safety problems in the home, and make sure what the patients are supposed to do to manage their own care realistically can be incorporated into their everyday life," she says.

Home visits can help clinicians identify issues that clinicians could never find out during an office visit, points out Kathleen Mylotte, MD, director for quality and disease management at Independent Health Association in Buffalo, NY. Her organization's Care Partners for Frail Elders provides home visits for eligible Medicare Advantage members with chronic conditions to help them avoid preventable complications and medical emergencies.

Nurses and social workers visit eligible seniors in their homes to check their health status, support them in following their care plan, and coordinate care with their primary care physician. They link patients with community resources such as transportation services, support groups, and financial assistance and arrange for home health care when needed.

"This program is unique in terms of putting eyes and ears in the home. Someone in an office setting who is talking with a patient may miss key pieces of the patient's situation. When our staff visits the home, they can see issues around safety, medication duplication, evidence of abuse or other social issues, transportation problems, and nutritional issues that never could be uncovered in the office setting," Mylotte says. For instance, a patient may tell the physician or nurse that he is eating well, but a look at the refrigerator and cupboards will indicate that he is subsisting on tea and toast.

When visiting in the home, the Care Partners staff have the ability to talk to family members, friends, and neighbors that they wouldn't see during an office visit. In addition, seeing people in their homes over long periods of times makes them aware of when the member is failing or needs more assistance.

Kristy Duffey, MS, BNP-BC, vice president of clinical operations for Baltimore-based XLHealth, adds that by integrating a spectrum of care management services, the company's Care Improvement Plus, XLHealth's Medicare health plan, has reduced hospitalizations and emergency department visits among chronically ill members. The Chronic Conditions Special Needs Plan includes in-home visits, telephonic nurse care management, pharmacist assistance, social services, a transitions-in-care component, and an advanced illness program for members in the final stages of life.

"Far too many seniors with chronic conditions have repeat hospitalizations and emergency department visits. By offering a collection of population-based and individualized patient outreach programs that all are interrelated, we hope to break this cycle and help our members stay healthy at home," she says.

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